OSPI School District/Instructor Registration

OSPI School District/ Instructor Registration

If your school district is registered under the Office of Superintendent of Public Instruction (OSPI), you can register with us to submit student permit waivers and completion certificates electronically. You must have access to a computer to enter certificates electronically.

Email this registration to OSPI Traffic Safety Education at K12TSE@k12.wa.us Or mail to: OSPI Traffic Safety Education, PO Box 47200, Olympia WA 98504-7200

When you receive the approved copy of this registration from OSPI Traffic Satey Education go to . You will upload this document in the online process.

For questions or language help call (360) 902-3703 or email tse@dol.. Allow two weeks for processing.

Registration type New Renewal

School district

TYPE or PRINT School district name

DOL certificate number

Physical address of school district (Address, City, State, ZIP code)

District (Area code) Phone number

Mailing address of school district, if different (Address, City, State, ZIP code)

Contact name (Main point of contact for school district)

Contact title

(Area code) Phone number Email

TSE coordinator

(Area code) Phone number Email

Superintendent

(Area code) Phone number Email

High schools

1 High school name

Physical address (Address, City, State, ZIP code)

Status

Add Delete

DOL certificate number

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

2 High school name Physical address (Address, City, State, ZIP code)

Status

Add Delete

DOL certificate number

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

Continue to page 2 if you need additional space for high schools. Continue to page 3 Instructors if you don't.

DTS-661-026 (R/5/21)WA Page 1 of 4

Copy this page if you will need additional space for high schools. High schools?continued

3 High school name

Physical address (Address, City, State, ZIP code)

Status

Add

Delete

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

4 High school name Physical address (Address, City, State, ZIP code)

Status

Add Delete

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

5 High school name Physical address (Address, City, State, ZIP code)

Status

Add Delete

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

6 High school name Physical address (Address, City, State, ZIP code)

Status

Add Delete

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

7 High school name Physical address (Address, City, State, ZIP code)

Status

Add Delete

Mailing address, if different (Address, City, State, ZIP code)

Contact name

Contact title

(Area code) Phone number

Email

DOL certificate number DOL certificate number DOL certificate number DOL certificate number DOL certificate number

Continue to page 3 Instructors.

DTS-661-026 (R/5/21)WA Page 2 of 4

Copy this page if you will need additional space for instructors.

Instructors?Required for new and renewal applications. All classroom and behind-the-wheel instructors

must register for access to our portal. Attach additional pages if needed.

1 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy) OSPI use only

Approved

DOL certificate number

(Area code) Phone number

Email

Registration type

Instructor Examiner Knowledge only

2 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

3 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

4 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

5 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

6 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

7 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

8 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

9 Name exactly as it appears on their driver license/ID card (Last, First, Middle initial/name)

Date of birth (mm/dd/yyyy)

DOL certificate number

(Area code) Phone number

Email

OSPI use only Approved

Registration type

Instructor Examiner Knowledge only

DTS-661-026 (R/5/21)WA Page 3 of 4

Certification

Answer the following

1. Is this school district operating a traffic safety education program that follows the approved/ required curriculum maintained by the Office of the Superintendent of Public Instruction and the Department of Licensing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

2. Does the program meet the course delivery standards approved by the Office of the Superintendent of Public Instruction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

3. Does the program have a record retention policy in place to meet the requirements of RCW 28A.220.030(5)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

4. Has the school district verified that all instructors are authorized by the Office of the Superintendent of Public Instruction to teach a driver training education course.? . . . . . . . . . Yes No

I declare under penalty of perjury under the law of Washington that the foregoing is true and correct.

TYPE or PRINT Name of Superintendent

X When you have completed this form, please print it out and sign here.

Date and place signed

Superintendent signature

DTS-661-026 (R/5/21)WA Page 4 of 4

Application received (date)

OSPI use only Reviewed by (OSPI)

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